1861029076 NPI number — DR. GEORGE LEONARD ETTEL III DO

Table of content: DR. GEORGE LEONARD ETTEL III DO (NPI 1861029076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861029076 NPI number — DR. GEORGE LEONARD ETTEL III DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETTEL
Provider First Name:
GEORGE
Provider Middle Name:
LEONARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861029076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
502 W HIGHLAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INVERNESS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34452-4720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7050 AIR DEPOT BLVD BLDG 1094
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TINKER AFB
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73145-8716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-667-0390
Provider Business Practice Location Address Fax Number:
405-736-3619
Provider Enumeration Date:
03/26/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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